Provider Demographics
NPI:1447375761
Name:JACKMAN, PAMELA D (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 E MAIN ST
Mailing Address - Street 2:STE 4
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844
Mailing Address - Country:US
Mailing Address - Phone:407-329-3442
Mailing Address - Fax:407-329-8170
Practice Address - Street 1:651 E MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-4241
Practice Address - Country:US
Practice Address - Phone:407-329-3442
Practice Address - Fax:407-329-8170
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7486235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889413200Medicaid